Patient Factors Associated With Return to Driving Poststroke: Findings From a Multicenter Cohort Study

Association of Age and Neurological Severity at Intensive Care Unit Admission With Driving Resumption Within 30 Days of Stroke: A Single-Center Historical Cohort Study

Objectives Guidelines in several countries recommend against driving soon after a stroke; however, some patients resume driving within one month after onset. This study aimed to examine the relationship between neurological and social background factors at intensive care unit (ICU) admission and resumption of motor vehicle driving within 30 days of the first acute stroke/cerebral hemorrhage. Materials and methods Data were extracted from medical records of a single center linked to the National Cerebral and Cardiovascular Center Administration Office for Stroke Data Bank in Japan. The data included age, sex, Japan Coma Scale (JCS), National Institutes of Health Stroke Scale (NIHSS), employment status, family situation, and outcomes of driving resumption in patients with a valid driving license transported to the ICU within 24 hours of stroke onset. Time-to-event analysis was used to explore the associations between these factors and driving resumption, with data censored 30 days from onset. Results In total, 239 patients had complete medical records, of whom 66 resumed driving. A multivariate Cox proportional hazards analysis showed that fewer patients aged ≥65 years resumed driving than those aged <65 years (hazard ratio 0.46; 95% confidence interval: 0.25-0.84; p=0.009). Patients with NIHSS scores ≥5 and JCS scores ≥1 were also less likely to resume driving compared with those with scores <5 (0.22; 0.08-0.56; p=0.008) and 0 (0.13; 0.04-0.37; p<0.001), respectively. Conclusions Age, NIHSS score, and JCS score at ICU admission are independently associated with the likelihood of resuming driving within 30 days of stroke onset. These findings may aid with the provision of support and education to facilitate the efficient resumption of driving after an acute event.

The relationship between Rating of Everyday Arm-use in the Community and Home (REACH) scale affected arm-use assessment, activity and participation after stroke

BACKGROUND AND OBJECTIVES

While arm function has been traditionally used as a primary goal for upper extremity rehabilitation post-stroke, we propose a simple measure of arm use, which may translate into better activities and participation. The aim was to determine the relationship between arm use and measures of activity and participation.

METHODS

This was a cross-sectional study with evaluative components involving community-dwelling individuals with chronic stroke. The Rating of Everyday Arm-Use in the Community and Home (REACH) Scale was used to assess affected arm use, Barthel Index and activity domain of the Stroke Impact Scale (SIS) for activities, and participation domain of the SIS for participation. The participants were also asked if they resumed driving after the stroke.

RESULTS

Forty-nine individuals (mean age = 70.3 ± 11.5 years, male sex = 51%) living with the effects of a stroke for at least 3 months participated in this study. There was a positive relationship between affected arm use and activities (Barthel Index score - rs  = 0.464; SIS activities - rs  = 0.686), participation (rs  = 0.479), and driving (rs  = 0.581). The Barthel Index scores were higher for individuals with dominant arm hemiparesis (p = 0.003) or left hemisphere lesions (p = 0.005). There was also greater arm use in left hemisphere lesions (p = 0.018).

CONCLUSIONS

Affected arm use in individuals with chronic stroke is related to activities and participation. Given the importance of arm use in activities and participation after stroke, rehabilitation therapists may consider utilizing the REACH Scale, a simple and quick outcome measure, as a means to assess arm use and implement effective interventions for improving arm use.

Development of an assessment form for the performance of public transportation use in individuals with stroke

PURPOSE

To develop a new assessment form that is assessed by therapists for the performance of public transportation use for stroke survivors through content validation.

MATERIALS AND METHODS

The items for the tentative assessment form were selected using hierarchical clustering analysis on previous records of 76 field-based training sessions for public transportation use for stroke survivors. After the modification of the tentative form based on 6 months of clinical use, the final form was developed through content validation using the Delphi method by 71 therapists who had been working at the hospital for more than 2 years and had experience with training for public transportation use.

RESULTS

The Public Transportation use Assessment Form (PTAF) for stroke was successfully developed through three validation processes. It consists of four categories (plan for going out, mobility, using trains, and using buses) including 15 items that cover various tasks of public transportation use. The scoring for each was as follows: 3, independent; 2, requires supervision of verbal assistance; 1, requires assistance; and N, not applicable.

CONCLUSION

The PTAF, developed through content validation, could assess the ability of public transportation use, and identify specific problems for each stroke survivor in clinical setting.IMPLICATIONS FOR REHABILITATIONWe developed the Public Transportation use Assessment Form (PTAF) to assess the ability of stroke survivors to use public transportation.The PTAF could identify specific problems related to public transportation use for stroke survivors and aid in planning rehabilitation programs based on the results.The PTAF could share information about which task need support in public transportation use and could augment the hospital discharge plan.

Driving Rehabilitation for Stroke Patients: A Systematic Review with Meta-Analysis

Driving enables stroke survivors to freely participate in social integration. The purpose of this review was to summarize the evidence for the therapeutic effects of driving rehabilitation for patients when they return to driving after stroke and evaluate the predictors of returning to driving to identify the factors impacting their driving rehabilitation. This study employed a systematic review and meta-analysis. PubMed and four other databases were searched until 31 December 2022. Our review included randomized controlled trials (RCT) and non-RCTs that investigated driving rehabilitation for stroke and observational studies. A total of 16 studies (two non-RCT and 14 non-RCT) were reviewed; two RCTs investigated the effect of driving rehabilitation with a simulator system, and eight and six non-RCTS evaluated the predictive factors of driving return post-stroke and compared the effects of driving rehabilitation for stroke, respectively. The National Institute of Health Stroke Scale (NIHSS) and Mini Mental State Examination (MMSE) scores and having paid employment were significant predictors of resuming driving after stroke. The results suggest that NIHSS, MMSE, and paid employment are predictors of returning to driving post-stroke. Future research should investigate the effect of driving rehabilitation on the resumption of driving in patients with stroke.

Stroke Recurrence among Stroke Patients Referred for Driving Assessment and Rehabilitation: A Cohort Study

Returning to driving is one of the priorities for stroke survivors. However, the fear of the risk of recurrent stroke has led to concern about allowing driving post-stroke. This study was performed to study the impact of various vascular risk factors on stroke recurrence among drivers referred to our national referral center for Driving Assessment and Rehabilitation Program (DARP). Medical records of subjects who were diagnosed to have a stroke and were referred to DARP were retrospectively reviewed. Data on demographics (age and gender) and vascular risk factors (hypertension-HT, diabetes mellitus-DM, hyperlipidemia-HL, cigarette smoking-SM, previous stroke-PS, and heart disease-HD) were collected. Subjects were contacted and records scrutinized for a report of recurrent stroke. A total of 133 subjects were recruited, median 54 years (range 20-77 years), 95.5% male, 59.4% had HT, 32.3% DM, 65.4% HL, 43.6% SM, 3.8% PS, and 8.3% HD. Over a median follow-up of 30 months (range 1-78 months), the recurrence rate of stroke was 11.3%, 3.69/100 patient-years. On uni-variable analysis, the risk of stroke recurrence rose with age (HR 1.08, 95%CI 1.02-1.15, p = 0.01) and heart disease (HR 5.77, 95%CI 1.46-22.83, p = 0.01). On multivariable analysis, only age remained significant (HR 1.07, 95%CI 1.00-1.13, p = 0.045). Among those aged > 60 years, the HR was 3.88 (95%CI 1.35-11.20, p = 0.012). The risk of stroke recurrence is higher among older drivers and is not influenced by other vascular factors.

Social Environmental Factors Related to Resuming Driving after Brain Injury: A Multicenter Retrospective Cohort Study

Many patients resume driving after brain injury regardless of their ability to drive safely. Predictors for resuming driving in terms of actual resumption status and environmental factors are unclear. We evaluated the reasons for resuming driving after brain injury and examined whether social environmental factors are useful predictors of resuming driving. This retrospective cohort study was based on a multicenter questionnaire survey at least 18 months after discharge of brain injury patients with rehabilitation. A total of 206 brain injury patients (cerebrovascular disease and traumatic brain injury) were included in the study, which was conducted according to the International Classification of Functioning (ICF) items using log-binominal regression analysis, evaluating social environmental factors as associated factors of resuming driving after brain injury. Social environmental factors, inadequate public transport (risk ratio (RR), 1.38), and no alternative driver (RR, 1.53) were included as significant independent associated factors. We found that models using ICF categories were effective for investigating factors associated with resuming driving in patients after brain injury and significant association between resuming driving and social environmental factors. Therefore, social environmental factors should be considered when predicting driving resumption in patients after brain injury, which may lead to better counseling and environmental adjustment.

Foundational Study on the Simple Detection of Impairment Resulting in Dangerous Driving in Patients with Higher Brain Dysfunction

OBJECTIVES

We performed a survey of medical records to reveal the cognitive deficits behind dangerous driving in patients with higher brain dysfunction.

METHODS

Thirty-four patients with higher brain dysfunction were included in this study. Patients' basic characteristics, neuropsychological test results, scores on two types of driving aptitude tests, and accident/near miss data from a driving simulator were extracted from medical records. We conducted χ2 tests for independence between comprehensive driving aptitude scores and "traffic accidents" / "being prohibited from driving as defined by the number of traffic accidents and near misses." Backward logistic regression analysis was carried out to assess correlations of "traffic accidents" and "being prohibited from driving as defined by the number of traffic accidents and near misses" with neuropsychological test scores.

RESULTS

No significant correlation was observed between the comprehensive driving aptitude score and "traffic accidents" / "being prohibited from driving as defined by the number of traffic accidents and near misses." The score on the Raven's Colored Progressive Matrices test was the only factor identified as a significant predictor of "being prohibited from driving as defined by the number of traffic accidents and near misses."

CONCLUSIONS

The results of this study suggest that it is important to focus on the decline in problem-solving ability as a predictor of "being prohibited from driving as defined by the number of traffic accidents and near misses."

Post-stroke fatigue: A factor associated with inability to return to work in patients <60 years-A 1-year follow-up

This study investigated the association between post-stroke fatigue and inability to return to work/drive in young patients aged <60 years with first stroke who were employed prior to infarct while controlling for stroke severity, age, extent of disability, cognitive function, and depression. The Fatigue Severity Scale (FSS) was used to evaluate post-stroke fatigue in this 1-year prospective cohort study. Follow-ups were completed at 3, 6, and 12 months post rehabilitation discharge. A total of 112 patients were recruited, 7 were excluded, due to loss to follow-up (n = 6) and being palliative (n = 1), resulting in 105 participants (71% male, average age 49 ±10.63 years). Stroke patients receiving both inpatient and outpatient rehabilitation were consecutively recruited. Persistent fatigue remained associated with inability to return to work when controlling for other factors at 3 months (adjusted OR = 18, 95% CI: 2.9, 110.3, p = 0.002), 6 months (adjusted OR = 29.81, 95% CI: 1.7, 532.8, p = 0.021), and 12 months (adjusted OR = 31.6, 95% CI: 1.8, 545.0, p = 0.018). No association was found between persistent fatigue and return to driving. Fatigue at admission was associated with inability to return to work at 3 months but not return to drive. Persistent fatigue was found to be associated with inability to resume work but not driving. It may be beneficial to routinely screen post-stroke fatigue in rehabilitation and educate stroke survivors and employers on the impacts of post-stroke fatigue on return to work.

Return to driving post stroke; patients' perspectives and challenges in Saudi Arabia

BackgroundReturning to driving remains one of the most important goals for stroke survivors. In Saudi Arabia, there are no structured processes to address the issue of return to driving in individuals with disabilities. There are increasing rates of strokes in the country and road traffic accidents are the highest in the region. Returning to driving among male stroke survivors in Saudi Arabia is of particular importance due to socio-economic and cultural reasons.AimsThe study aims to explore the factors involved in return to driving among stroke survivors in Saudi population.MethodsThis cross-sectional study was carried out on 100 male stroke survivors who had completed an inpatient rehabilitation program and had at least one follow-up assessment three months post-discharge. Information was collected regarding demographics, stroke characteristics, and factors related to pre and post-stroke driving. Data were analyzed using SPSS.ResultsMajority (60%) of patients were 51 years of age and above. Most commonly reported stroke impairments were weakness and spasticity with majority of participants having right-sided body involvement. Out of 94 stroke survivors who were driving prior to stroke, only 7 resumed driving. None of the stroke survivors who returned to driving reported receiving any formal driving assessment. Only one patient who reported being aware of the need of driving assessment did not resume driving after stroke.ConclusionsThere is a dire need to increase awareness and to develop a structured integrated system in Saudi Arabia to facilitate stroke survivors to return to driving.

Community Rehabilitation Outcomes for Different Stroke Diagnoses: An Observational Cohort Study

Objective

To determine the differences in functional and cognitive rehabilitation gains made in community-based rehabilitation following a stroke based on stroke diagnosis (left or right hemisphere, hemorrhagic, or ischemic).

Design

A 12-month follow-up observational retrospective cohort study.

Setting

Staged community-based brain injury rehabilitation.

Participants

Clients (N=61) with hemorrhagic left brain stroke (n=10), hemorrhagic right brain stroke (n=8), ischemic left brain stroke (n=27), or ischemic right brain stroke (n=16) participating in rehabilitation for at least 12 months.

Intervention

Not applicable.

Main Outcome Measures

The Mayo-Portland Adaptability Inventory-4 (MPAI-4) was completed at admission and 12 months post admission to staged community-based brain injury rehabilitation by consensus of a multidisciplinary team.

Results

After 12 months in staged community-based brain injury rehabilitation, the study population made significant gains in Total (P<.001) and across Ability (P<.001) and Participation (P<.001) subscales of the MPAI-4. All diagnostic groups made significant gains in Participation T-scores, and no groups made significant gains in Adjustment. The ischemic left and right hemisphere stroke groups also made significant gains in Ability and Total T-scores from admission to 12 months. Clients with ischemic left hemisphere stroke had more severe limitations in motor speech (P<.05) than clients with right hemisphere stroke at admission and/or review and were also more impaired in verbal communication (P<.01) than the hemorrhagic right hemisphere group at admission.

Conclusions

There are some differences in outcomes on presentation to rehabilitation based on type of stroke; there are also differences in rehabilitation gains. Improvement in physical ability does not always translate to improvement in social participation and independence; those with right brain stroke need further assistance to translate physical gains into participatory outcomes.

Predicting fitness-to-drive following stroke using the Occupational Therapy - Driver Off Road Assessment Battery

Introduction: It is difficult to determine if, or when, individuals with stroke are ready to undergo on-road fitness-to-drive assessment. The Occupational Therapy - Driver Off Road Assessment Battery was developed to determine client suitability to resume driving. The predictive validity of the Battery needs to be verified for people with stroke. Aim: Examine the predictive validity of the Occupational Therapy - Driver Off Road Assessment Battery for on-road performance among people with stroke. Method: Off-road data were collected from 148 people post stroke on the Battery and the outcome of their on-road assessment was recorded as: fit-to-drive or not fit-to-drive. Results: The majority of participants (76%) were able to resume driving. A classification and regression tree (CART) analysis using four subtests (three cognitive and one physical) from the Battery demonstrated an area under the curve (AUC) of 0.8311. Using a threshold of 0.5, the model correctly predicted 98/112 fit-to-drive (87.5%) and 26/36 people not fit-to-drive (72.2%). Conclusion: The three cognitive subtests from the Occupational Therapy - Driver Off Road Assessment Battery and potentially one of the physical tests have good predictive validity for client fitness-to-drive. These tests can be used to screen client suitability for proceeding to an on-road test following stroke. Implications for Rehabilitation: Following stroke, drivers should be counseled (including consideration of local legislation) concerning return to driving. The Occupational Therapy - Driver Off Road Assessment Battery can be used in the clinic to screen people for suitability to undertake on road assessment. Scores on four of the Occupational Therapy - Driver Off Road Assessment Battery subtests are predictive of resumption of driving following stroke.

A Systematic Review and Meta-Analysis of On-Road Simulator and Cognitive Driving Assessment in Alzheimer's Disease and Mild Cognitive Impairment

BACKGROUND

Many individuals with Alzheimer's disease (AD) and mild cognitive impairment (MCI) are at an increased risk of driving impairment. There is a need for tools with sufficient validity to help clinicians assess driving ability.

OBJECTIVE

Provide a systematic review and meta-analysis of the primary driving assessment methods (on-road, cognitive, driving simulation assessments) in patients with MCI and AD.

METHODS

We investigated (1) the predictive utility of cognitive tests and domains, and (2) the areas and degree of driving impairment in patients with MCI and AD. Effect sizes were derived and analyzed in a random effects model.

RESULTS

Thirty-two articles (including 1,293 AD patients, 92 MCI patients, 2,040 healthy older controls) met inclusion criteria. Driving outcomes included: On-road test scores, pass/fail classifications, errors; caregiver reports; real world crash involvement; and driving simulator collisions/risky behavior. Executive function (ES [95% CI]; 0.61 [0.41, 0.81]), attention (0.55 [0.33, 0.77]), visuospatial function (0.50 [0.34, 0.65]), and global cognition (0.61 [0.39, 0.83]) emerged as significant predictors of driving performance. Trail Making Test Part B (TMT-B, 0.61 [0.28, 0.94]), TMT-A (0.65 [0.08, 1.21]), and Maze test (0.88 [0.60, 1.15]) emerged as the best single predictors of driving performance. Patients with very mild AD (CDR = 0.5) mild AD (CDR = 1) were more likely to fail an on-road test than healthy control drivers (CDR = 0), with failure rates of 13.6%, 33.3% and 1.6%, respectively.

CONCLUSION

The driving ability of patients with MCI and AD appears to be related to degree of cognitive impairment. Across studies, there are inconsistent cognitive predictors and reported driving outcomes in MCI and AD patients. Future large-scale studies should investigate the driving performance and associated neural networks of subgroups of AD (very mild, mild, moderate) and MCI (amnestic, non-amnestic, single-domain, multiple-domain).

Driving in stroke survivors aged 18–65 years: The Psychosocial Outcomes In StrokE (POISE) Cohort Study

Background

There is limited information regarding return to driving after stroke.

Aims

To determine the frequency and predictors of return to driving within 1 month of acute stroke in younger (age 18–65 years) adults.

Methods

POISE (Psychosocial Outcomes In StrokE) was a cohort study conducted in Australia between October 2008 and June 2010. Consecutive patients (age 18–65 years) with a recent (≤28 days) acute stroke were recruited. Validated demographic, clinical, mental health, cognitive, and disability measures including return to driving were obtained. Multivariable logistic regression was used to determine factors associated with return to driving within 1 month of stroke.

Results

Among 359 participants who were legally able to drive before stroke, 96 (26.7%) returned to driving within 1 month. Compared to those without an early return to driving ( n = 263), drivers were more often male, the main income earner, in paid work before stroke and without symptoms of depression or fatigue. Independence in activities of daily living (odds ratio (OR) 30.05, 95% confidence interval (CI) 3.85–234.45), not recalling receiving advice on driving cessation (OR 5.55, 95% CI 2.86–11.11), and having returned to paid work (OR 3.93, 95% CI 1.94–7.96) were associated with early return to driving.

Conclusions

One in four young adults resumed driving within a month, contrary to guideline recommendations. These data reinforce the importance of deciding who is responsible for determining fitness to drive after stroke, when, and whether it is reasonable to enforce driving restrictions on those with minimal disability who are fit to return to work.

Registration

Australian New Zealand Clinical Trials Registry ANZCTRN 12608000459325.

Guidelines for Adult Stroke Rehabilitation and Recovery: A Guideline for Healthcare Professionals From the American Heart Association/American Stroke Association

PURPOSE

The aim of this guideline is to provide a synopsis of best clinical practices in the rehabilitative care of adults recovering from stroke.

METHODS

Writing group members were nominated by the committee chair on the basis of their previous work in relevant topic areas and were approved by the American Heart Association (AHA) Stroke Council's Scientific Statement Oversight Committee and the AHA's Manuscript Oversight Committee. The panel reviewed relevant articles on adults using computerized searches of the medical literature through 2014. The evidence is organized within the context of the AHA framework and is classified according to the joint AHA/American College of Cardiology and supplementary AHA methods of classifying the level of certainty and the class and level of evidence. The document underwent extensive AHA internal and external peer review, Stroke Council Leadership review, and Scientific Statements Oversight Committee review before consideration and approval by the AHA Science Advisory and Coordinating Committee.

RESULTS

Stroke rehabilitation requires a sustained and coordinated effort from a large team, including the patient and his or her goals, family and friends, other caregivers (eg, personal care attendants), physicians, nurses, physical and occupational therapists, speech-language pathologists, recreation therapists, psychologists, nutritionists, social workers, and others. Communication and coordination among these team members are paramount in maximizing the effectiveness and efficiency of rehabilitation and underlie this entire guideline. Without communication and coordination, isolated efforts to rehabilitate the stroke survivor are unlikely to achieve their full potential.

CONCLUSIONS

As systems of care evolve in response to healthcare reform efforts, postacute care and rehabilitation are often considered a costly area of care to be trimmed but without recognition of their clinical impact and ability to reduce the risk of downstream medical morbidity resulting from immobility, depression, loss of autonomy, and reduced functional independence. The provision of comprehensive rehabilitation programs with adequate resources, dose, and duration is an essential aspect of stroke care and should be a priority in these redesign efforts. (Stroke.2016;47:e98-e169. DOI: 10.1161/STR.0000000000000098.).

Examining the relationship between fatigue and cognition after stroke: A systematic review

Many stroke survivors experience fatigue, which is associated with a variety of factors including cognitive impairment. A few studies have examined the relationship between fatigue and cognition and have obtained conflicting results. The aim of the current study was to review the literature on the relationship between fatigue and cognition post-stroke. The following databases were searched: EMBASE (1980-February, 2014), PsycInfo (1806-February, 2014), CINAHL (1937-February, 2014), MEDLINE (1946-February, 2014), Ethos (1600-February, 2014) and DART (1999-February, 2014). Reference lists of relevant papers were screened and the citation indices of the included papers were searched using Web of Science. Studies were considered if they were on adult stroke patients and assessed the following: fatigue with quantitative measurements (≥ 3 response categories), cognition using objective measurements, and the relationship between fatigue and cognition. Overall, 413 papers were identified, of which 11 were included. Four studies found significant correlations between fatigue and memory, attention, speed of information processing and reading speed (r = -.36 to .46) whereas seven studies did not. Most studies had limitations; quality scores ranged from 9 to 14 on the Critical Appraisal Skills Programme Checklists. There was insufficient evidence to support or refute a relationship between fatigue and cognition post-stroke. More robust studies are needed.

Predictors of return to driving after stroke

OBJECTIVE

Although returning to driving is a major concern for many survivors of stroke, predicting who will return to driving after a stroke is often difficult for rehabilitation professionals. The primary aim of this study was to identify patient factors present at admission to an inpatient rehabilitation hospital that can be used to identify which patients who have had acute stroke will and will not return to driving.

DESIGN

After comparing returners and nonreturners on demographic and clinical characteristics, a logistic regression model with return to driving as the outcome variable was built using the backward stepwise method.

RESULTS

Thirty-one percent (48/156) of the patients who had been driving before their stroke returned to driving 6 mos after stroke. The final regression model, using Functional Independence Measure cognition and lower extremity Motricity Index scores, predicted the driving outcome with an accuracy of 75% (107/143).

CONCLUSIONS

Patients with lower Functional Independence Measure cognition and lower extremity Motricity Index scores at admission to inpatient rehabilitation are less likely to return to driving at 6 mos. This model could be used by rehabilitation professionals to help counsel patients and their families and focus treatment goals.

Stroke rehabilitation

Despite improvements in prevention and acute management, stroke remains a common condition and a major cause of permanent disability. For patients who have had a stroke, an effective rehabilitation program is critical to maximize functional recovery and quality of life. Rehabilitation can occur in a number of different physical settings and is often coordinated by a comprehensive interdisciplinary team of professionals. Rehabilitation includes retraining to regain loss of function and teaching compensatory strategies when that is not possible. A number of interesting training approaches have been developed in recent years to supplement more traditional rehabilitation programs. A variety of adaptive devices is available to improve mobility and performance of self-cares, and these devices should be prescribed for appropriate patients. Physicians caring for patients during stroke rehabilitation must be aware of potential medical complications, as well as a number of special problems that may complicate recovery, including dysphagia, urinary incontinence, shoulder pain, spasticity, falls, and poststroke depression. Involvement of the patient and caregivers in the rehabilitation process is essential. It is important to train and educate these individuals in the physical aspects of poststroke care, the expectations for recovery, and secondary stroke prevention. Issues related to community reintegration, including driving and vocational aspects, should be addressed in appropriate patients. Stroke rehabilitation is an important part of the "stroke continuum of care," which includes prevention, acute management, rehabilitation, and secondary prevention.

Frequency and natural history of fatigue after stroke: a systematic review of longitudinal studies

BACKGROUND

Fatigue is a common and distressing symptom after stroke. Stroke survivors and health professionals need to know whether fatigue is likely to improve, or get worse over time; and whether there is a temporal association with depression or anxiety, which might provide a target for treatment,

AIMS AND OBJECTIVES

To systematically review all longitudinal observational studies which have assessed fatigue on at least two separate time points after stroke onset to determine its frequency, natural history and temporal relationship with anxiety and/or depression.

METHOD

We systematically searched MEDLINE, EMBASE, CINAHL and PsychInfo using the keywords "fatigue" and "stroke" and their associated terms or synonyms. Data were extracted regarding time points after stroke where fatigue was assessed, frequency of fatigue at each time point and any reported associations with anxiety and/or depression.

RESULTS

101 full texts were retrieved after scrutinising the titles and abstracts. Nine fulfilled our inclusion criteria. Fatigue was assessed at a variety of time points after stroke (from admission -to 36 months). The frequency of fatigue ranged from 35%-92% at the first time point. Frequency of fatigue declined across time points in seven of the studies (n=764) and increased in two studies (n=195). Three papers found significant associations between fatigue and mood at the same time point. The single study investigating temporal associations between fatigue and mood disorders reported that depression predicted subsequent fatigue.

CONCLUSIONS

Fatigue is present soon after stroke onset and remains common in the longer term. There is little evidence regarding the temporal relationship between fatigue and mood: this is an area where further research is needed.